Seeking Perfection in Healthcare:
Applying the Toyota Production
System to Medicine
“Leading the Revolution”
Association for Manufacturing Excellence
J. Michael Rona Christina Saint Martin
“If you are dreaming about it…
you can do it.”
Chihiro Nakao, Chairman and CEO Shingijutsu International
Leading the Revolution
Virginia Mason Medical Center is trying to create a
better product. Perhaps when the industry looks
back, we will be looked upon as one system that
helped “Lead the Revolution”
“Leading the Revolution”
Customer First Zero Defects
Virginia Mason Medical Center Strategic Plan
An Embarrassingly Poor Product
The March 16, 2003 edition of The New York Times
Magazine front cover reads, “Half of what doctors know is wrong.”
The lead story is titled “The Biggest Mistake of Their
Lives” and chronicles four survivors of medical errors.
The article goes on to say that in 2003, as many as
98,000 people in the United States will die as a result of medical errors.
“System of Secrecy Potentially Puts Patients at Risk”
The Bitter Bottom Line of Medical Errors
Kidney
transplant on the wrong side (U.C.L.A.) Surgical sponge and gauze left in a breast Unnecessary radical jaw surgery Surgical tool left in stomach
Virginia Mason Medical Center November 23, 2004
Investigators: Medical mistake kills Everett woman
Hospital Complications Exceed $9 Billion
(Study based on data from 994 hospitals in 2000.)
0 10 20 30 40 50 60 $60,000 12 days Bedsores Accidental Puncture Infection Caused by Medical Care Blood-stream Infections Wound Reopening Foreign Object Left Inside Body Excess charges, Left scale Excess length of stay, right scale 10 8 6 4 2 # Patients affected annually Mortality rate 7.23% 2.16% 4.31% 21.92% 9.63% 2.14% 41,440 11,810 11,449 2,592 843 536
“Costs Continue to Rise”
$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 2000 2002 2004Annual Health Benefit Cost Per Covered
Person
Why Zero Defects is the
Only Acceptable Standard
At 99.9% quality levels, here is what happens:
22,000 checks are deducted from the wrong bank
accounts every day
16,000 pieces of mail are lost by the Postal Service
every hour
2,000 unsafe airplane landings are made every day 500 incorrect surgeries are completed every week
Seeing with our Hands…
Japan 2002
What We Learned
Air conditioners, cars, looms, airplanes and forklifts...What do any of these products have to do with health care?
• Health care, too, is full of production processes
• These Japanese products, like our services, involve the concepts of quality, safety, customer satisfaction, staff satisfaction and cost effectiveness
• The completion of a product involves thousands of processes—many of them very complex
• Many products, if they fail, can cause fatality
• Production processes have much in in common with
admitting a patient, having a clinic visit, going to surgery or a procedure and sending out a bill
• To have smooth, high quality continuous flow of our patients is delightful when it happens
• Our vision is that this would happen always for our patients
• We are more convinced than ever that the principles and tools of the Toyota Production System may well become those of the Virginia Mason Production System, the system of management behind the achievement of becoming the Quality Leader
The Plan
The plan for translating what we learned into reality at Virginia Mason has seven areas of focus:
1. “Patient First” as the driver for all that we do
2. The Virginia Mason Production System will be our our brand of the Toyota Production System
3. The creation of an environment in which our people feel safe and free to engage in improvement – The adoption of a “No Layoff Policy”
4. Implementation of a company-wide defect alert system called “The Patient Safety Alert System” 5. Encouragement of innovation
6. Creating a prosperous economic organization by primarily eliminating waste
7. Accountable Leadership
VMPS at Virginia Mason
We adopted the Toyota Production System philosophies and practices and applied them to healthcare because this industry and we were so lacking in an effective
management approach that resulted in:
Customer first
Highest quality
Obsession with safety
Highest staff satisfaction
A successful economic enterprise
The Impact of Lean
½ the human effort
½ the space
½ the equipment
½ the inventory
½ the investment
½ the engineering hours
Validated Industry Averages
Direct Labor/Productivity Improved 45-75%
Cost Reduced 25-55%
Throughput/flow Increased 60-90%
Quality (Defects/Scrap) Reduced 50-90%
Inventory Reduced 60-90%
Space Reduced 35-50%
Lead Time Reduced 50-90%
Summarized results, subsequent to a 5-year evaluation, from numerous companies (over 15
A reduction of 34 miles!! A reduction of 70 miles!! A reduction of 702 Days!!
Stopping the Line
™
Virginia Mason’s Patient
Safety Alert System
™
Stopping the Line
™
Intervention Concepts
Safety hazards are process defects
Process defects are least harmful and
easiest to fix
at the time
they arise
Process defects are more harmful and
Stopping the Line
™
Concepts and System
Everyone
is an inspector
Everyone
can stop defects
If the process cannot be stopped from making
defects,
the process must stop
Patient Safety Alert Process
™Created (8/2002)
Leadership from the top
“Drop and run” commitment 24/7 policy, procedure, staffing Legal & reporting safeguards
Patient Safety Alert
™
Case Study 9: Mixing of
Medications
1) A patient presented to Dermatology Clinic for removal of a pigmented lesion.
2) A medical assistant prepared two 5 ml syringes containing an intended mixture of:
4.5 ml 1% lidocaine with epinephrine 0.5 ml 8.4% sodium bicarbonate.
3) The physician injected the contents of the first 5 ml syringe into the skin. The patient immediately reported unusual discomfort and a lack of
Case Study: Incident 9
Mixing of Medications
4) The physician suspected that the quantities of lidocaine and bicarbonate had been reversed
when the solution was mixed. The procedure was aborted. The patient was informed of the
suspected error. Pharmacy was called for advice. 5) The patient’s was observed in the clinic for 1 hour
and then released to home with continuing follow-up.
Patient Safety Alert
™
Case 9 – Day 1
Notification
Patient Safety Alert Initiated
Physician, Dermatology
Leadership Notified
CEO, President, Sr. Vice President,
Vice President Quality and Compliance, Chief of Medicine, Administrative Director
Patient Safety Alert
™
Case 9 – Day 1
Stopping the Line
The “line was stopped” for the current process of
injectable medication mixing
involvement of medical assistants
A “buddy” system was immediately initiated to verify
appropriate mixing of injectable medications
Patient Safety Alert
™
Case 9 – Day 2 &3
Issues Identified
High variation in practice
No standard process for mixing and administration
of injectable medications
High variation in process to assure that medical
assistants have appropriate competency and certification for mixing injectable medications
Patient Safety Alert
™
Case 9 – Days 2-12
Improvements
Developed standard process for an acceptable method
of mixing injectable medication
Developed standard process for assuring that medical
assistants have appropriate competency and certification for mixing injectable medication
Cumulative Declared PSA’s
18 143 347 4430
100
200
300
400
500
2002
2003
2004
Mar-05
Number
[800]
Distribution of Declared PSA’s
56% 15% 13% 8% 8% Systems Medication Errors Diagnosis & Treatment Facilities & Equipment Professional Conduct as of 3/31/05Average PSA’s per Month
4 10 17 320
5
10
15
20
25
30
35
40
45
50
2002
2003
2004
2005
as of 3/31/05Number
Days to Completion of PSA
18 13 14 110
5
10
15
20
25
2002
2003
2004
2005
as of 3/31/05Number
Offline During Investigation
2002 2003 2004 2005
Employees
6
5
14
6
Equip/Process
1
4
8
2
Virginia Mason Results
The Cost of Error
Mistake Proofing and Improvement
FTE Trends
Learnings from Production Preparation
Process (3P)
Cost Avoidance and Savings
RPIW Roll Up
The Cost of Error
Ventilator Acquired Pneumonia
2002 Cases
34
Est. Deaths 5
2002 Cost
$ 500,000
Professional Liability Expense
Claims Paid ²
$ 4.6 Million
Claims Paid ³
$ 4.5 Million
Mistake Proofing
Ventilator Acquired Pneumonia
Cases in 2002: 34 Cost in 2002: $500,000 Cases in 2005: 1 Cost in 2005: $15,000 * Projected 2005 Est. Deaths 5 Est. Deaths 0
Staffing Trends
Full Time Equivalents
1996:
2890
1997:
3264
▲
1998:
3467
▲
1999:
3528
▲
2000:
3612
▲
2001:
3647
▲
2002:
3656
▲
2003:
3581
▼
2004:
3562
▼
3P’s: Production, Preparation, Process
Cancer
Hospital
Dermatology
GI
Hyperbarics
3P Dermatology Model – “Skin
”
The patient would enter and exit through a peaceful, quiet “museum like” environment. (See center of model)
Along the walk, the patient would be provided with education about skin care and the services that VMMC Dermatology provides. Images would be projected up on plasma screens projected through frosted glass. (See sample/photos on the next page)
The Concierge (Water Strider) would serve as tour guide through this area, offering
the patient information and suggest skin products for purchase. Calming music and aromatherapy will add to the ambiance. “Circles” of Specialty Dermatology care are placed in specific areas. The Moh’s Specialty area, for instance, is located where the patient can enter and exit
privately. This model is patterned after the Kitchen Triangle Model where each Specialty Circle would serve 1 provider and 2 MA’s. There are no waiting rooms in this model, expecting one-piece flow to Takt time.
Cost Avoidance
• 1M Capital Savings for Hyperbaric Chamber from 3P
• 1-3M Endoscopy Suites now staying in current location
• 6M Surgery Suites budgeted and planned - now not building
• Hospital 3P
• Lead Time, Staffing, Space
• Cancer 3P
• Same amount of space 120 pts per day to 188 pts per day (57% increase)
What hasn’t worked
Lots of activity but not enough traction
Safety vs. Waste and Flow
Scope too big
Hit the wrong target
0 50 100 150 200 250 300 2000 2001 2002 2003 2004 2005 2006
Virginia Mason RPIW Activity
Strategies Revisited:
How do we really get there?
Infrastructure
Education
Focus of RPIW’s/Kaizen Events
3P
Everyday Lean
Accountability
Improving the Infrastructure:
Critical to implementation
Focused goals aligned with organizational goals
Explicit measurable targets
Accountability for implementation and sustained
results
Enhanced leadership structure
Enhanced “gemba” support
Improvement never ends and is full-time work
¾ Specialists
¾ Training & Education
¾ Tools & Materials
¾ Data/Statistics
¾ RPIW/3P Calendar
¾ 3P Support
¾ Events/Website
¾ Strategy & Planning ¾ Goals
¾ KPO Implementation Plans ¾ Audit
¾ Community/Communications ¾ Consulting
President
J. Michael Rona
Senior Vice President Hospital Administrator
Sarah Patterson
Senior Vice President Clinic Administrator Patti Crome VMPS Operations Susie Creger Rosemary King Operations Managers Corporate KPO Linda Hebish, AD Doug Grove, AD Erin Ressler, Lead Specialist
3 Specialists
Clinic KPO
Liz Dunphy, AD John Eusek, AD Pat Pethigal, Lead Specialist
3 Specialists
Hospital KPO
Katerie Chapman, AD Val Ferris, AD Chris Backous, Lead Specialist
3 Specialists ¾ KPO Planning ¾ Kaizen Events ¾ RPIWs ¾ Everyday Lean ¾ KPO Planning ¾ Kaizen Events ¾ RPIWs ¾ Everyday Lean ¾ KPO Planning ¾ Kaizen Events ¾ RPIWs ¾ Everyday Lean
Virginia Mason Production System Administration
Christina Saint Martin, Administrative Director
Virginia Mason Production System 2005 Management Structure
0 20 40 60 80 100 120 140 160 180 2000 2001 2002 2003 2004 2005 2006
Virginia Mason RPIW Activity
VMPS Educational Strategies
Everyday Lean Idea Campaign – All Staff
Intro to VMPS (course) – All Staff HES requirement Leading 5S – Management leads and teaches staff
Value Stream Mapping – Management course/All staff in 2006 Standard Operations – Management course/All Staff in 2006
Mistake Proofing – Management course/All Staff HES requirement Lean Mastery Track – Management course & collaborative
Workshop Leader Certification – Senior management requirement Kaizen Fellowship – Select senior management
Japan Gemba Kaizen – Management & staff 3P Certification
Everyday Lean Idea System
Three Ground Rules Rule #1:
Proposals involve creatively changing the
approach to our jobs or work unit to reduce waste and add value for our patients. Kaizen means we continuously improve using lean thinking
principles and strategic plan goals to either eliminate an activity, reduce the steps of an activity, or change the activity.
Rule #2:
Proposals are practical to try out on a small scale ourselves or with our coworkers’ help. They can be implemented almost immediately with little or no extra cost.
Rule #3:
To Change Medicine…..
Change Your Mind
Provider First Waiting is Good
Errors are to be Expected At-risk Employment
OTJ Training
Diffuse Accountability Add Resources
Reduce Cost
Retrospective Quality Assurance Management Oversight We Have Time Patient First Waiting is Bad Defect-free Medicine Guaranteed Employment Explicit Training Rigorous Accountability No New Resources Reduce Waste
Real-time Quality Assurance Management On Site
Ongoing Challenges
Culture Change
Professional Autonomy “People are Not Cars” Belief in Zero Defects
Rigor, Alignment, Execution Victimization
Scarcity v. Abundance Leadership Constancy